18 Sutton Avenue ROD Fee City of Salem Department of Planning and Community Development
Check Receipt and Tracking Form
Please complete the form and make two (2) copies
Date Received G
Amount Received ( 0 5 .0c)
Form of Payment MCheck ❑ Money Order
Client Information f1 On wen uC
Arts& Culture Land Use Boards
❑ Artists' Row Rent ❑ Planning Board Application Fee
❑ Charlotte Forten Plaza Use Fee ❑ SRA/DRB Fee
Payment received for ❑ Derby Square Plaza Use Fee ❑ ZBA Fee
❑ Old Town Hall Rental Fee ❑ Peer Review Fee
what service? ❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment ��2t'1 nah g��,��Gh
Additional Notes
l S U �-�cqn h ve yt U e - s , cn Ran Fec
}yyyyyyf}yyf'r�44}yl'f3K)�Y►�fS3'J�k�'f31!'�f'1SK4�SS4!'f3�3W
Jt31!}���3�K}}y}yyyl�SlY�4'r444Yr4�YrNlS'�YrS?1�f43�SS� � 163
JONATHAN C MAGNUSON 10 08
57-1l Po
2g BLAKELEY ST 53� 5s000
LYNN,MA 01905-1830
Pare
•M
is 00
par To me ,SS e,7� ` 5 `1
Order Of I � �r 9 Dollars Q a
(�U11 JIr 0"One
gankof America'��I
ACH RIT 011500010 �--- -------OP
1:0 11 S000 LOi: 00 394 1908 2 2 +'0 16 3
{1111t1dit{hilt% l�fK1111{t�K
MWWd�ltltt K1�1EKK1t1K1�lK1tt �ttfl�dd1t1t11�t'ffltltKlt#tYK1f�t+
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required